Appointment of Veterans Service Organization as Claimant's Representative and Appointment of Individual as Claimant's Representative (VA Forms 21-22 and 21-22a)

Forms and Documents

Document Name	Status
Form 21-22 Appointment of Veterans Service Organization as Claimant's Representative 'and' Appointment of Individual as Claimant's Representative Form	Modified
30-Day FRN (2900-0321)(4-30-15).pdf Supplementary Document	2015-05-04
60-Day FRN (2900-0321)(2-18-15).pdf Supplementary Document	2015-05-04
OMB2900-0321(21-22 21-22a)(8-13-15).docx Supporting Statement A	2015-08-13

IC Document Collections

IC ID	Document Title	Status
28538	Appointment of Veterans Service Organization as Claimant's Representative 'and' Appointment of Individual as Claimant's Representative Form	Modified

ICR Details

OMB Control No: 2900-0321	ICR Reference No: 201501-2900-011
Status: Historical Active	Previous ICR Reference No: 201203-2900-015
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DB
Title: Appointment of Veterans Service Organization as Claimant's Representative and Appointment of Individual as Claimant's Representative (VA Forms 21-22 and 21-22a)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/17/2015
	Date Received in OIRA: 05/27/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved	08/31/2015
Responses	331,400	0	331,400
Time Burden (Hours)	27,616	0	27,616
Cost Burden (Dollars)	0	0	0

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Abstract: VA Forms 21-22 and 21-22a are used to gather information that is necessary to determine whom claimants have appointed to represent them in claims for VA benefits. Without this information, VA would be unable to determine whom has been appointed as the representative, the extent of the representation, and access to appropriate records.

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Authorizing Statute(s): US Code: 38 USC 5903 Name of Law: Recognition with respect to particular claims
   US Code: 38 USC 5902 Name of Law: Recognition of representatives of organizations
   US Code: 38 USC 5701 Name of Law: Confidential nature of claims
   US Code: 38 USC 7332 Name of Law: Confidentiality of certain medical records
   US Code: 38 USC 5702 Name of Law: Furnishing of records
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32	02/18/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 83	04/30/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Appointment of Veterans Service Organization as Claimant's Representative 'and' Appointment of Individual as Claimant's Representative	21-22, 21-22A	Appointment of Veterans Service Organization as Claimant's Representative ,   Appointment of Individual as Claimant's Representative

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	331,400	331,400	0	0	0	0
Annual Time Burden (Hours)	27,616	27,616	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,181,939

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/27/2015

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